Harborview doctor suspected abuse of 4-month-old baby who died

Testimony in David Paul murder trial to continue Tuesday

David J. Paul, 24, left, and Assistant Public Defender Eric Hedland listen to Assistant District Attorney Nicholas Polasky in Juneau Superior Court on Friday. Paul is on trial in the death of 4-month-old Rian Jambi Orr in August 2010.

Juneau Superior Court Judge Philip Pallenberg, center, listens to Assistant District Attorney Nicholas Polasky, right, and Assistant Public Defender Eric Hedland make a arguement during the trial of David J. Paul on Friday for the death of Rian Jambi Orr in August 2010.

The primary physician caring for Rian Jambi Orr at Harborview Medical Center testified Friday that the “constellation of her injuries” caused him to suspect the 4-month-old had been abused.

Dr. Thomas Brogan said he consulted with the hospital’s Suspected Child Abuse & Neglect team after observing bleeding in Orr’s brain (bilateral subdural hematoma), cerebral swelling and uncontrollable seizures as well as prior injuries including bruises on her chest, rib fractures and a femur (thigh bone) fracture.

“A 4-month-old can’t get herself into that kind of trouble,” Brogan said under questioning from Assistant District Attorney Angie Kemp as the trial against Orr’s 24-year-old father David J. Paul entered its second day. “One has to postulate she was abused, more than once.”

Doctors worked to save Orr, who had been medevaced from Bartlett Regional Hospital in Juneau to Harborview in Seattle on Aug. 9, 2010. But her conditioned only worsened, and a decision was made to transition to end of life care, or “comfort care,” to ease her suffering. She was taken off life support on Aug. 15, 2010, and died later that evening. Brogan signed a death summary listing Orr’s cause of death as severe brain injuries and subdural brain hemorrhaging.

Prosecutors charged Orr’s mother’s live-in boyfriend, David Paul (who was listed as the baby’s father on the birth certificate and who raised Orr as his own, but was not Orr’s biological father) with two counts of murder and one count of manslaughter in connection to her death about a year after the fact. If convicted, he could be facing 99 years in prison for murder and 20 years for manslaughter.

The state’s theory is Paul accidentally dropped Orr and shook her once to make her stop crying the morning of Aug. 9, and that Orr died of something akin to Shaken Baby Syndrome, or as it’s called now Abusive Head Trauma. The defense, meanwhile, says Orr did not die from injuries suffered that morning, but that she had a chronic subdural hematoma and a clotting problem that went unnoticed until that day.

On Friday, Paul’s defense attorney Assistant Public Defender Eric Hedland questioned Brogan’s findings by suggesting Brogan abided by the theory of child abuse to make sense of all of Orr’s symptoms absent another explanation.

Brogan conceded under cross-examination that it may be circumstantial to assume Orr’s prior injuries were evidence of child abuse. But even without those prior injuries, Brogan said, he still would have reached the same conclusion — that Orr’s injuries were inflicted by another person.

When explaining why, however, Brogan said what the defense was striving to establish: in assessing Orr’s brain injuries and seizures, “you have to put all those together into a coherent picture.”

“You try to pin all of the symptoms on one cause if you can,” Brogan said.

Hedland has established through medical testimony so far that many things can cause seizing, that seizing does not always manifest itself with physical movement (meaning it could potentially go unnoticed) and that babies can be born with subdural hematomas.

Hedland also suggested that Brogan’s opinion could have been influenced early on by incorrect information from a CT scan done at BRH which indicated Orr had an epidural hematoma rather than a subdural hematoma. While that made no difference in Orr’s treatment, Hedland argued it could have caused doctors to initially associate Orr’s injuries with child abuse since epidural hematomas usually occur from skull fractures from blunt-force trauma. In contrast, subdural hematomas can be caused by a variety of things, such as non-blunt force trauma, abnormal ability to clot blood or vascular malfunctions, as Brogan testified. (Orr did not have a skull fracture.)

Hedland called into question why Orr did not have retinal hemorrhaging, one of the three apparently tell-tale symptoms of Shaken Baby Syndrome. That was determined later during the autopsy since Orr was too sick and unstable to be seen by an eye doctor at Harborview.

Hedland also introduced a medical report from Aug. 13, written by a resident at Harborview and cosigned by her attendees, that indicated the cause of Orr’s injuries was listed as unknown and that non-accidental trauma was still a possibility. An addendum to the report stated the patient’s case was presented at a meeting (at which Brogan was not present) and the general consensus among the doctors was that the cause of the injuries was unclear. In response, Brogan said under cross that the neurologists at that meeting were not experts in child abuse.

Under re-direct, ADA Kemp said Paul did not tell doctors either at BRH or Harborview that he accidentally dropped Orr the morning of Aug. 9, leaving doctors with an incomplete medical history while treating Orr.

“Nobody ever gave a story that would explain her injuries,” Brogan said.

“Rian is a child who had bleeding in the brain and brain swelling, and so you have to put those two things together,” he added.

Brogan also testified he thought the hematoma was acute (meaning recent or ongoing) rather than chronic, and that a clot would not explain the swelling in Orr’s brain.

Jaki Orr

Testimony is slated to continue on Tuesday, possibly with Orr’s mother Jacqueline Orr, who goes by Jaki, on the witness stand. Due to scheduling conflicts, Jaki was examined by prosecutors on Thursday and Friday, but she has not been fully cross-examined yet.

On Friday, she recalled the hospital stay at Harborview and expressed guilt at not spending more time with her daughter. She testified that at that time Paul was already a suspected child abuser, and consequently he was prohibited from being around the baby. The couple ended up spending more time with each other outside of the hospital than with Orr. Jaki said at that time she also thought Orr was going to recover.

“I feel terrible,” she said in between sobs. “Because I can’t go back and spend that time with my daughter.”

The doctors eventually confronted her with a decision on whether to take Orr off life support. Jaki said she decided to after doctors told her there was no way to know whether Orr was in any pain or suffering.

The couple waited in a hospital room as Orr breathed on her own and fought for her life. After 11 or so hours, the two decided to take a quick break to get coffee. By sheer bad luck, that’s when Orr passed.

Jaki combated the defense’s portrayal of her as a “disinterested” mother by stating she was the baby’s primary caretaker and changed more diapers than Paul did. The jury saw pictures taken by Jaki of her and her daughter smiling and looking at the camera.

She said she took her prenatal vitamins as instructed, and her lack of weight gain during her pregnancy wasn’t for lack of trying — she said she currently weighs 98 pounds and has always struggled to put on weight.

Under examination from Assistant District Attorney Nicholas Polasky, Jaki said there were a few times during their relationship that Paul mistreated Orr. She said a couple of times when Paul was playing video games and Orr was crying, Paul raised his voice at her and told her to “shut up.” Another time he lightly tossed a blanket over Orr to muffle the sounds of her crying, Jaki testified.

The morning of Aug. 9, Jaki said she woke up to get ready for the day at about 9:30 a.m. She said she observed some things wrong with her baby (including a feeble whimper — “As if she had woken up from a nightmare,” eyes that wouldn’t fully open and body movements that weren’t right). Jaki continued getting ready for the day and placed Rian in the carseat in the bathroom as she and Paul showered together, a part of their normal routine. She peeked out during the shower to watch Orr and noticed Orr’s arms and legs go rigid, then limp. Then, she saw Orr’s eyes roll back in her head. That’s when she figured out Orr was having seizures.

The couple got dressed and drove to Juneau Urgent Care and were instructed to drive to BRH. A few hours later, Orr was being airlifted to Harborview with her mother by her side. Already a suspect, Paul was forbidden by authorities to be on the medevac flight and he made his own arrangements to travel to Seattle.

Jaki testified that the night before on Aug. 8, Orr was “perfectly fine.” She said she asked Paul if anything had happened in the meantime and that he had said no.

Jaki noted under the few minutes of cross-examination that she and Paul stayed together after Orr’s death and had a baby together, 15-month-old Anthony. She said he was born on Christmas Day 2011. (Previously on Thursday, Jaki mistakenly said Anthony was born Christmas Day 2012.)

She said she talked on the phone with Paul, who was indicted and arrested in July 2011, while he was incarcerated. She left without his knowing in February 2012 to Missouri where she now lives with her family.